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EMAIL CONSENT FORM

By signing below, I, _______________________ of legal age consent to the use of email communication between myself and
______. I recognize that there are risks to its use, and despite the Center’s best efforts, they cannot absolutely guarantee privacy and
confidentiality. I understand and accept the risks outlined below:

 E-mail can be viewed by unintended persons.

 E-mail can also be circulated, forwarded and stored in paper and electronic files.
 Backup copies may exist even after the sender and recipient have deleted his/her copy.
 Emails may be intercepted, altered, forwarded or used without authorization or detection.

I also understand that I may withdraw my consent to communicate via email at any time by notifying the Management in writing.

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Signature over Printed Name
Date: __________________